<div class="content-wrapper">
    <div class="container">
        <div class="row pad-botm">
            <div class="col-md-12">
                <h4 class="header-line">Register To FCPAA</h4>
            </div>
        </div>

        <div class="row">

            <div class="col-md-2 col-sm-4 col-xs-6">
                <div class="alert alert-info back-widget-set text-center alert-zs">
                    <i class="fa fa-arrow-right fa-5x"></i>
                    <h3>Information</h3>
                </div>
            </div>
            <div class="col-md-2 col-sm-4 col-xs-6">
                <div class="alert alert-warning back-widget-set text-center alert-zs">
                    <i class="fa fa-arrow-right fa-5x"></i>
                    <h3>Packages</h3>
                </div>
            </div>
            <div class="col-md-2 col-sm-4 col-xs-6">
                <div class="alert alert-warning back-widget-set text-center alert-zs">
                    <i class="fa fa-arrow-right fa-5x"></i>
                    <h3>Addresses</h3>
                </div>
            </div>
            <div class="col-md-2 col-sm-4 col-xs-6">
                <div class="alert alert-warning back-widget-set text-center alert-zs">
                    <i class="fa fa-arrow-right fa-5x"></i>
                    <h3>Statement</h3>
                </div>
            </div>
            <div class="col-md-2 col-sm-4 col-xs-6">
                <div class="alert alert-warning back-widget-set text-center alert-zs">
                    <i class="fa fa-arrow-right fa-5x"></i>
                    <h3>Login</h3>
                </div>
            </div>

        </div>  
        <div class="row">
            <div class="col-md-12">
                <div class="alert alert-info alert-zs">
                    <p>Thank you for your interest in becoming an FCPAA Member. To apply for FCPAA Membership, please enter the following information and you will be added to or system. </p>
                    <p>If you have previously registered on this site and have forgotten your username or password, you may request a new one.</p>
                </div>
            </div>
        </div>        

        <div class="row">

            <div class="col-md-12">
                <div class="panel panel-info panel-zs">
                    <div class="panel-heading">
                        Information
                    </div>
                    <div class="panel-body">
                        <form role="form" id="reg_form">
                            <input type="hidden" name="page" value="reg">
                            <div class="form-group">
                                <label>Prefix</label>
                                <select class="form-control" name="prefix">
                                    <option value="Capt.">Capt.</option>
                                    <option value="Dr.">Dr.</option>
                                    <option value="Miss">Miss</option>
                                    <option value="Mr.">Mr.</option>
                                    <option value="Mrs.">Mrs.</option>
                                    <option value="Ms.">Ms.</option>
                                </select>
                            </div>
                            <div class="form-group">
                                <label>First Name *</label>
                                <input class="form-control" name="first_name" type="text" />
                            </div>
                            <div class="form-group">
                                <label>Middle name</label>
                                <input class="form-control" name="middle_name" type="text" />
                            </div>
                            <div class="form-group">
                                <label>Last Name (Surname) *</label>
                                <input class="form-control" name="surnames" type="text" />
                            </div>
                            <div class="form-group">
                                <label>City</label>
                                <input class="form-control" name="city" type="text" />
                            </div>
                            <div class="form-group">
                                <label>Country</label>
                                <input class="form-control" name="country" type="text" />
                            </div>
                            <div class="form-group">
                                <label>Phone *</label>
                                <input class="form-control" name="phone" type="text" />
                            </div>
                            <div class="form-group">
                                <label>Email *</label>
                                <input class="form-control" name="email" type="text" />
                            </div>

                            <button type="button" class="btn btn-info" id="reg">Next</button>
                            <a href="javascript:history.go(-1);" type="button" class="btn btn-default">Back</a>

                        </form>
                    </div>
                </div>
            </div>
        </div>
        <!--/.ROW-->    
    </div>
</div>
